Stooping To Greatness, Part 2

Yesterday, I ran into an “old” former colleague.  It had been years.  First thing he said: “How is that we look so old now?”  I never liked him.  Ha!  🙂

The truth is that it was great to reconnect.  Coincidentally, he’s in the midst of solving some of these same cultural puzzles for his new organization.  We talked about Part 1 over lunch.

A couple key points when beginning this new culture adventure …

  • There’s a huge difference between the sugar-rush, Diet Dr. Culture & Built-To-Last Cultures.

    Most staff have seen the Mission/Vision/Whatever that comes down from the Ivory Corporate Tower.  They are forced to attend the meetings and trainings, often delivered by corporate types or half-heartedly by facility leaders.  During those meetings, they are very quietly grabbing each others hands with a knowing nod: “This too shall pass.”  And, they’re right.  It won’t last because they (the staff) didn’t give birth to it.

No longer collecting dust on the wall.
No longer collecting dust on the wall.  You can’t make this up.  In the basement of my facility, I was looking around for some equipment.  I turned on the light and saw these artifacts from the prior facility occupants.  I don’t know what caused them to fail.  But they did.  Anecdotally, I’ve seen this play out time and again.  Where there is no vision, the people perish.  Without a vision/culture that actually inspires (or at least captures their hearts and minds), you’re programs become artifacts.
  • The GIVING BIRTH metaphor.

    I’m a guy.  I’m no expert.  I know.  But, I’m a father of 5, does that count for anything?!  Here’s the metaphor that fits so well here: Establishing your company/facility’s culture should be like giving birth.  There’s power in the creative process.  There’s a massive difference psychologically (for buy-in/commitment) if I’m able to participate in defining the culture (expectations, standards, rewards, etc.) as opposed to having Know-It-Alls present it to me.  If I go through the labor of wrestling with the words, values, mottos, standards, and behaviors that we want for our workplace, and then the delivery of agreeing to and training new hires in it, then I will be committed to the final product in a way that I simply can’t if it’s presented to me … let me illustrate:

    • Several years ago I went through this creative process for the first time at a building I ran in Orange County, CA.  Our before and after scoreboard made many in the organization take note and ask me to share our “secret sauce” as we went from worst to first in some key metrics like EBITDAR PPD.  I was more than happy to share.  It felt like I was on tour as I presented to more than 1/2 of our facilities.  I would spend an entire day with a facility’s leadership team – presenting to them the what, how, why, and when of World Class Service, which is what we labeled the culture we gave birth to.  The immediate response from those many facility teams was, by-and-large, enthusiastic.  They wanted to do the same thing at their buildings.  They wanted to do it right away.  I gave them our Mission & Standards documents.  I gave them our Orientation packet.  I gave them our Daily, Weekly, Monthly system for making the culture take root.Poster-BWC-[Converted]-Outline
    • Poster-BWC-Standards-[Converted]-OutlineAnd, then I left to the next facility.  I hit rewind and repeat.  Over and over again.  I personally felt tremendous excitement about making a difference beyond my facility.  I felt appreciation from ED/DNS partnerships who were looking for that missing thing to take them to the next level.  They found it.  They believed.  And, except for a handful of facilities, most of their efforts fizzed out within 3 to 6 months.Why?  I’ve thought a lot about that.  Ultimately, I believe two things are absolutely required in order to transform your culture into a transformative force:
      1. The Executive Director must be a “true believer(not the regional or the divisional or the owner at the home office)

      2. S/he must lead her/his facility through their own creative process.  They must reinvent the wheel instead of adopting someone else’s wheel (no matter how successful that wheel made that someone else).

If this is true, then the questions become what, why, how, and when to recreate the wheel.  The Birds And The Bees, if you will, of how cultures are made (I couldn’t resist).  Culture Birds & Bees.  That’ll be part 3 next.

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Nursing Home Institution vs. Resident Centered Approach

The Next 10 years …

This all started about 2 months ago when my wife and I were on a walk, talking about my short career in long-term care.  I marveled that I had been with the same company (The Ensign Group) for 9 years.  AIT-Administrator of 3 facilities-AIT Program/Leader Development/Support guy …

That walk/talk stimulated a lot of reflection in what I want out of my next 10 years.  A strong desire (maybe need?) has risen to the surface to take my (and our company’s) experience and do something transformative with it for the benefit of today’s and tomorrow’s long-term care residents.  That could sound a little quixotic (side note: Don Quixote: One of my all time favorite stories/inspirations and a great motivating tool for staff) but I think it’s actually a pretty common experience for people in long-term care.  As I looked in the 9 year mirror I see myself on this curve:

Empathy Curve in Healthcare
Empathy Curve in Healthcare

 

As an AIT I started out like most — fired up, wanting to treat each resident like family, eager to learn and improve this embattled industry.  The empathy I felt was very high.  Feeling sorry for a lot of the long-term residents who had no family support.  Feeling a bit shocked at the scene of a resident being wheeled down on a PVC pipe roller chair to the shower room covered only with a sheet — leaving a trail of diarrhea.  Feeling nauseated by the smells during certain procedures.  How do I, having never worked in a nursing home before, get used to that?!  Feeling pretty impotent to change things for the better until I learn why they’re done this way in the first place.  What have I gotten myself into?

So what happens/happened?

You start to cope.  I suppose we all cope differently.  But as you cope, you ‘fall’ not just on the empathy curve but into a too-casual relationship with the profession.  Some signs of the coping fall …

  • You call Virginia in room 24 bed A by a different name: 24-A, ‘the hip’, Medicare Patient, etc.  This dehumanizing of ‘Virginia’ helps you cope with all of the residents you’ve let down some way.  It also speeds up communication with the others at the facility who don’t really know Virginia.
  • You are less shocked by the sights, sounds, and realities of life as a nursing home resident.
  • You rationalize away your loss of empathy as not a loss of empathy but as a better understanding of why things are always done that way.
  • You spend your time on delivering the things your company measures regardless of how in line with your values or vision those measurements are.
  • You don’t smell the smell that first-timers do.  🙂

You survive for a while and then you begin to thrive.  Your experience and success builds confidence to experiment, to find YOUR VOICE.  You begin to need more than simple survival.  Maslow’s Hierarchy of Needs illustrates a theory of the different levels of human need that you see in yourself as an administrator.  This analogy is a bit forced but you’ll get the idea.

You first need to survive.  That ‘Physiological’ need means you have to not lose your job 🙂  You need to learn, perform to how your measured, fit in, etc.  With some time and success your needs graduate to the ‘Safety’ need.  Here you pass some surveys; you put a team together; you learn from your mistakes; you change your style to be more effective.  You start to float between Safety and ‘Belonging’ as you find some balance in your life. you perform well financially; you’re recognized in your organization as an important partner.  The trouble is … this is the bottom of the Empathy Curve.  You may stay here for the rest of your career, quite comfortable.

Maslow's Hierarchy of Needs
Maslow’s Hierarchy of Needs

But with time, you start to feel a need to do more with what you’ve received.  You feel a need to not only run an outstanding facility, but to transform long-term care in the eyes of the residents.  You wrestle with some tough questions as you confront the brutal facts …

  • What truly makes us different from our competition (in the eyes of the community)?  Wouldn’t our competitors say that they are nice and caring just like we say?  What can only we say about being a resident here that our competition cannot?
  • Is it a significantly better experience to be a resident in my facility than at an average facility elsewhere?  In other words, is sleeping, waking up, getting dressed, eating breakfast, going to activities, going to therapy, receiving medications, etc. a significantly better experience than your average facility?

You feel a higher need pulling you up from the coping gravity to see things (again) from the residents’ perspective.  You are extremely proud of surviving and then succeeding at one of the most difficult jobs anywhere.  You are proud of how you’ve treated your employees (for the most part).  You are proud of the company you’ve helped grow.  You are proud of the facilities that have improved qualitatively and quantitatively under your leadership.  Now what?

Now you feel a new, familiar need to change the industry.  You feel a need to fight the CALF PATHS and the gravity that limits our vision of what we can and should do.

The difference between that need/empathy today vs. when you began is that now you have the knowledge and wherewithal (what a great catch-all word) to do something about it.

There are a handful of companies and leaders in long-term care that are ‘ahead of the curve’ (get it?) when it comes to changing the industry.  BUT, it seems like the movement is way too slow.  One major initiative is the resident-centered approach as illustrated here.

Nursing Home Institution vs. Resident Centered Approach
Nursing Home Institution vs. Resident Centered Approach

I love the concept.  I think it is on target to where we need to take long-term care.  But, the cultural, financial, and regulatory obstacles are real and in many cases prohibitive for an administrator to experiment with.

For my next 10 years I want to work at clearing those obstacles away.  AND, more importantly, I want to figure out how to lessen the slope and duration of the drop and bottom of the empathy curve for others.  Skilled nursing companies have to find the right people, find the right measurements and establish a culture of entrepreneurship and innovation in order to do more than simply survive.  We and our residents ‘need’ it.

2 Questions

If you’re looking to transform your facility’s culture, 2 questions will turbo charge the change … regardless of where you’re trying to take your organization.  Training your staff (and rewarding and holding them accountable) to consistently ask these 2 questions will have an IMMEDIATE impact on your residents, patients, and outside community … guaranteed!

The impact of training your entire staff to ask these 2 questions CONSISTENTLY will yield the following results:

  • Improved resident/patient satisfaction
  • Reduced call lights
  • Reduced call light wait time
  • Prevented accidents
  • Increased Census

It’s a win-win and a no-brainer.  2 Questions to turbo charge your culture change efforts.  Good luck!

Administrator-Director of Nursing Diagnostics

During the last couple years I’ve visited with over 50 nursing home administrators and their department head teams to assist them
  1. Define their facility culture,
  2. Implement world class service practices,
  3. Strengthen their teams, and/or
  4. Improve their marketing efforts
I’ve had the pleasure of working with leaders at facilities everywhere across the spectrum of performance (from beginning of turnaround to market leaders).  While I find my work fulfilling and important, I’ve concluded that those numbered areas of focus above are SECONDARY to the area in the facility that is really the FOUNDATION of everything is the relationship between Administrator and Director of Nursing.  In fact, as I look back at most struggling situations (clinical, regulatory, financial) the vast majority of them involve a weak, strained, or dysfunctional ED-DNS ‘partnership.’
The opposite is also true!  Where there is a strong, trusting, caring relationship between the administrator and the DNS, real transformation can take place – given competent, inspired leaders.
All efforts toward cultural change, implementing higher standards, or improving the facility must come AFTER the ED-DNS relationship is solid.  Otherwise, the initiatives will be planted on a weak foundation and will fall by the wayside after a few months.  Unless there is a unified front where the ED-DNS are on the same page and are authentically committed to the initiative regardless of what it is, no change will be lasting.
In healthcare we rely on DIAGNOSTICS to identify the problem.
Diagnostics
Diagnostics
I’ve developed a cultural diagnostic tool for administrators and directors of nursing to assess how strong their relationship is.  Scoring themselves on a series of statements will not only give them a grand total but it serves as a powerful basis for conversation as the two most important facility leaders take steps toward that optimal ED-DNS relationship of trust.
A sample of the statements to be scored:
(Scoring:  3 = Always         2 = Sometimes          1 = Rarely)
  • We run decisions for hiring, firing, and discipline by each other regardless of position. We give each other a ‘heads up’ so there are no surprises.
  • Our loyalty to each other is greater than our loyalty to anyone else in the facility.
  • We leave meetings/conversations confident that we are both completely committed to the decisions that we agreed on, even if there was initial disagreement.

You get the idea.

We often wonder why bright ideas, great programs, change initiatives fail after 2 or 3 months in the facility.  This is why.  No matter how brilliant the program/system, if the ‘top’ is not first committed to each other and second committed to the brilliant program/system, it is destined to fail.  Get this relationship right.  You get the change (culture, clinical, etc.) you desire.

Of course, this assumes competent, inspiring administrators and directors of nursing to begin with.  More on how to find and retain those all-stars later …

Thou Shalt Not!

One of the biggest challenges in providing the highest level of service in healthcare is to undo the years of phrases and vocabulary that is so common and so destructive. We’ve all heard the following:

“She’s not my patient”
“That’s not my job”
“The other shift didn’t do it”
“There’s no supplies”
“There’s no time”
“I’m in a hurry”
Etc.

When we started our transformation, we started here … with vocabulary. We introduced Communication Guidelines in the form of “THOU SHALT NOT SAY …” All of the staff could relate to saying or hearing each one of the 10 phrases at some point. Like with all our training, we made it fun/funny as we introduced the new requirement.

Then … we laid down the law. We stated that saying any one of those prohibited words/phrases would be cause for termination. We were serious. We don’t want to lose any of you. Etc.

When we termed a CNA for saying “She’s not my patient,” the entire facility found out about it and realized we were, in deed, serious about the experience our patients/customers receive. After the employee was termed, behaviour changed … big time. There was a noticeable difference in the verbal communication with people in the facility … more polite. More aware.

Everyone’s been told not to say those things before. But, it is the full committment of the leadership of the facility (meaning willing to lose people) that is required to see the change take effect.

"Buy A Bus"

In October of 2004, we acquired a facility in Orange County, CA. It was there that the idea of “becoming the Ritz Carlton of skilled nursing facilities” first struck us …

A couple weeks before we took over the facility, the Dept. of Health called us in to their office to talk. It was there that we first realized what type of facility we were getting … a train wreck. DHS informed us that it was among their worst facilities in the county in terms of complaints and surveys (annual inspections). When I asked them why they thought it struggled so much for so long, their response surprised us … mainly a problem of geography – that our affluent area limited the number of strong employees.   When I asked what they recommended, they said “buy a bus and bus them in from Santa Ana and Anaheim.” After years of “dealing” with that facility, DHS saw buying a bus as the most feasible option.  What immediately followed, ALMOST made me take up their advice …

A few weeks after we took over, DHS showed up for our annual survey. And, in keeping with tradition, we failed it. Fines, penalties, and denial of payment for new admissions … not to mention the stress in preparing for a re-survey.  By the start of the second quarter, we were in the hole and tired. Looking back, that thrashing was really necessary to “prepare the soil.” Because of that experience, we were desperate not to repeat the same failure year after year and we started looking for what would address these pains we were feeling:

– Survey/Department of Health
– New Management
– Growing Census
– Feeling “Stuck” (internally & externally)
– What makes our building different from our competition?
– Recruiting
– Staffing
– Morale
– Financial Stress
– Survival Mode
– Customer Complaints

I think most SNFs experience these to one degree or another. We just happened to feel them all intensely at the same time 🙂

We identified something that would, theoretically, address all of those pains — and we found it at a training offered by the Ritz Carlton hotels. I attended their training that summer of 2005 in Los Angeles and was blown away. The initial skepticism (“We don’t look or smell like a Ritz”) and (“Their customers actually chose to be their customers — unlike our patients/residents”) started to melt away as the day went on. My “yeah but” turned into “I wonder if” to “why not?” In addition to the Ritz, we studied Disney and the Four Seasons …

We knew that radical change/commitment would be needed in order to become the ritz carlton of SNFs. But, frankly, we couldn’t see any other way out. We developed our own framework — including our Mission, Employee Promise, Motto, Customer Communication Guidelines, Service Definition, Guardian Angel Program, and Standards. We also developed training modules for each of these which included a test at the end of the training that every employee/and new hire had/has to pass in order to continue employment.

I’ll go into more detail later about the model … but, the results have been awesome as we’ve seen major improvements in the following:

– Staffing/Recruiting
– Reduced Complaints
– Improved Surveys
– Reduced Turnover
– Stronger Reputation & Census
– Provided hard, written standards to hold staff accountable and promote excellence
– Improved communication flow through Q Shift stand-ups
– Improved Financial Performance

What sounded good/right on paper turns out to be good/right in practice in this case. No remodel, re-landscaping, re-naming, re-anything could have the powerful impact on an organization that a fanatical commitment to world-class customer service standards can and does.

I hope this blog will serve both you and me to discover proven strategies and principles to bust out of the mediocrity in healthcare and achieve world class results.